Bulk cargoes, generally, have a tendency at some stage in the discharge operation to cease flowing and become hung-up. If the dedicated under-hold vibrators are unable to loosen the resulting residual piles of cargo, the piles are attacked by the crew using poles, spades, picks or, in extreme conditions, pneumatic drills. When dealing with fine coal cargoes, the crew have predetermined escape routes so that, in the event of a rapid evacuation of the area, their paths do not cross. The deceased and the other crew man had each agreed on, and had told the 00W of, their plan to deal with the coal pile. On this vessel such hang-ups of cargo are not unusual. A predetermined procedure to minimize risk is in place when men are sent to dislodge the hang-ups. Even though the procedure was observed before and during the placement of the men in No. 2 hold, neither of the two men was able to get completely free from the down-flowing coal when the cargo started to move. The fatality occurred because the predetermined procedure to minimize risk was not followed. The fatality emphasises the need for constant vigilance when men are working in potentially dangerous areas, and for ongoing research to find safer procedures.Analysis Bulk cargoes, generally, have a tendency at some stage in the discharge operation to cease flowing and become hung-up. If the dedicated under-hold vibrators are unable to loosen the resulting residual piles of cargo, the piles are attacked by the crew using poles, spades, picks or, in extreme conditions, pneumatic drills. When dealing with fine coal cargoes, the crew have predetermined escape routes so that, in the event of a rapid evacuation of the area, their paths do not cross. The deceased and the other crew man had each agreed on, and had told the 00W of, their plan to deal with the coal pile. On this vessel such hang-ups of cargo are not unusual. A predetermined procedure to minimize risk is in place when men are sent to dislodge the hang-ups. Even though the procedure was observed before and during the placement of the men in No. 2 hold, neither of the two men was able to get completely free from the down-flowing coal when the cargo started to move. The fatality occurred because the predetermined procedure to minimize risk was not followed. The fatality emphasises the need for constant vigilance when men are working in potentially dangerous areas, and for ongoing research to find safer procedures. Many shipboard operations are dangerous or hazardous but are dealt with by risk management, complemented by safe procedures and by well-trained officers and ratings. The predetermined procedure to minimize risk was not followed. It is not known why the deceased did not turn and run away from the downrush of coal. Low ambient temperatures may have caused a crust to form on the face of the coal pile, which may have caused a steeper angle of repose than 37o and hence a greater down-rush than would normally be expected.Findings Many shipboard operations are dangerous or hazardous but are dealt with by risk management, complemented by safe procedures and by well-trained officers and ratings. The predetermined procedure to minimize risk was not followed. It is not known why the deceased did not turn and run away from the downrush of coal. Low ambient temperatures may have caused a crust to form on the face of the coal pile, which may have caused a steeper angle of repose than 37o and hence a greater down-rush than would normally be expected. The deceased was overcome by a sudden fracture and down-flow from the face of the coal pile. Instead of turning and running from the wave of small coal, he backed away, apparently stumbled or tripped, fell on his back and was overcome and buried under the coal.Causes and Contributing Factors The deceased was overcome by a sudden fracture and down-flow from the face of the coal pile. Instead of turning and running from the wave of small coal, he backed away, apparently stumbled or tripped, fell on his back and was overcome and buried under the coal.